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Treating Out-of-Area TRICARE Beneficiaries
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With summer just around the corner, you may find yourself either treating a vacationing TRICARE beneficiary from another TRICARE region, or advising one of your own TRICARE beneficiaries on how to access out-of-area care. Because TRICARE beneficiaries may be covered by one of several TRICARE program options— e.g., TRICARE Prime or TRICARE Standard—with varying requirements for out-of-area care, it’s important that you be aware of those differences.
Is a Referral Required?
For emergency care services, TRICARE Prime and TRICARE Standard beneficiaries do not need a referral or authorization. They can go directly to any emergency room or call 911 for emergency care.
If a hospital inpatient admission occurs, a TRICARE Prime, TRICARE Prime Remote (TPR) or TRICARE Prime Remote for Active Duty Family Members (TPRADFM) beneficiary should contact his or her primary care manager (PCM) or regional contractor within 24 hours or the next business day to coordinate ongoing care. If the beneficiary is not admitted, the beneficiary will need to coordinate any follow-up care with his or her PCM. For those TPR active duty service members (ADSMs) or TPRADFMs without PCMs, beneficiaries should contact their regional contractor to coordinate all specialty follow-on care. A TRICARE Standard beneficiary also is encouraged to contact his or her primary care physician/family doctor.
If urgent care is required from a civilian provider, a TRICARE Prime, TPR or TPRADFM beneficiary must have a referral from his or her military treatment facility (MTF), PCM or regional contractor. Without a referral, urgent care is covered under the TRICARE point of service (POS) option, which translates into higher out-of-pocket costs for the beneficiary. Note: If the TRICARE Prime or TPRADFM beneficiary has other health insurance to provide the primary coverage, the POS option does not apply. TRICARE Standard beneficiaries do not need a referral for urgent care.
All TRICARE beneficiaries are instructed to receive routine care, when possible, from network providers in their designated regions.
Where Should Claims Be Submitted?
Regardless of the type of care—emergency, urgent or in rare cases, routine—provided to out-of-area TRICARE beneficiaries, other than active duty service members (ADSMs), they are responsible for payment of applicable cost-shares. You will submit all report and claims information to the region where TRICARE beneficiaries reside (and not the region in which they received care.) If you have any questions or concerns about submitting claims for out-of-area TRICARE beneficiaries, call the appropriate TRICARE regional contractor listed below.
North Region—Health Net Federal Services, LLC
1-877-TRICARE (1-877-874-2273)
The TRICARE North Region is comprised of the following areas: Connecticut, Delaware, the District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, Wisconsin and portions of Iowa (Rock Island Arsenal area), Missouri (St. Louis area) and Tennessee (Fort Campbell area).
West Region—TriWest Healthcare Alliance Corp.
1-888-TRIWEST (1-888-874-9378)
The TRICARE West Region is comprised of the following areas: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding the Rock Island Arsenal area), Kansas, Minnesota, Missouri (excluding the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner only, including El Paso), Utah, Washington and Wyoming.
Overseas—Wisconsin Physicians Service (WPS)
WPS is the claims processor for all overseas claims for beneficiaries residing in any of the TRICARE overseas regions—TRICARE Europe, TRICARE Latin America and Canada (TLAC), TRICARE Pacific or Puerto Rico and the Virgin Islands. Refer to Chapter 8 of the TRICARE Provider Handbook for the appropriate number to call based on beneficiary overseas residence.
For more information about treating out-of-area TRICARE beneficiaries, see Chapters 7 and 8 of the TRICARE Provider Handbook, or call Humana Military Healthcare Services, Inc. at 1-800-444-5445.
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