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TRICARE and Other Health Insurance
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Understanding how a TRICARE patient’s other health insurance (OHI) complements TRICARE benefits can help ensure that you receive timely and correct claims payments.
OHI is any non-TRICARE health insurance that a beneficiary—excluding active duty service members (ADSMs)—may receive from an employer or other public or private insurance program. TRICARE pays last after all OHI plans, except in the following instances:
Make sure you confirm your TRICARE patient’s OHI status on a regular basis so that coordination of benefits can occur. If OHI status changes, you must update your patient billing records to avoid delays in claims reimbursement.
Coordinating Referrals and Authorizations with OHI
Coordinating Referrals and Authorizations with OHI Humana Military Healthcare Services, Inc. (Humana Military) does not require referrals or prior authorizations when a benefi ciary’s OHI is the primary payer, except for the following covered services:
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Adjunctive dental care
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Behavioral health care services
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All nonemergency inpatient admissions for substance use disorder or behavioral health care
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Partial hospitalization programs and residential treatment center programs
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Psychotherapy after the initial eight outpatient visits
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Psychoanalysis
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Home health services
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Hospice care
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Solid organ and stem cell transplants
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TRICARE Extended Care Health Option (ECHO) benefits
However, if the OHI benefits are exhausted and TRICARE becomes the primary payer, additional referral and prior authorization requirements may apply.
Submitting OHI Claims
When TRICARE is the secondary payer, submit the claim to the primary insurer first. To coordinate benefits, supply the following information on the Centers for Medicare and Medicaid Services (CMS) 1500 Health Insurance Claim Form (CMS-1500):
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Indicate the sponsor’s full name in BOX 4. (Do not complete if “self” is checked in BOX 6.)
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Indicate the full name of the person with OHI that covers the patient in BOX 9, as well as the following additional information:
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Other insured’s policy or group number in BOX 9a
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Other insured’s date of birth and sex in BOX 9b
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Other insured’s employer name or name of school in BOX 9c
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Name of insurance plan or program name where individual has OHI in BOX 9d
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Mark “Yes” in BOX 11d indicating that there is an OHI plan primary to TRICARE.
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Indicate the amount paid by the OHI carrier in BOX 29.
You may not collect any out-of-pocket costs from a TRICARE beneficiary after the payment of a claim, unless OHI and TRICARE payments combined do not meet the following:
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The negotiated rate, if you are a network provider
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The TRICARE-allowable charge, if you are a non-network provider accepting assignment
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115 percent of the TRICARE-allowable charge, if you are a non-network provider not accepting assignment
For more information on filing OHI claims for TRICARE beneficiaries, refer to “TRICARE and Other Health Insurance” in Section 8 of the TRICARE Provider Handbook, or call PGBA at 1-800-403-3950.
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